VA, DoD investigate serious health record error

WFED's Max Cacas

The Department of Veterans Affairs and the Pentagon have some of their best people trying to unravel the truth behind a serious problem involving the health record of a soldier who just wanted to go back to Afghanistan to fight.

Normally, the Defense Department's health records system, called the Armed Forces Health Longitudinal Technology Application (AHLTA,) has a real-time data link to Vista, the health records system for the VA. The link lets certain medical information travel back and forth between the two systems to facilitate the care of soldiers and veterans following their active duty service.

But Roger Baker, VA's assistant secretary for information and technology and chief information officer said Thursday in a press conference with reporters that something went terribly wrong last month.

"We have a veteran who was scheduled for deployment that, based on information a DoD physician saw from that veteran's treatment at VA, determined that the veteran should not be deployed," Baker said.

For reasons of medical record privacy, the name of the affected member of the Army has not been revealed.

Baker revealed the incident in VA's monthly report on data breaches mandated by Congress. The report covers everything from lost or stolen laptops and desktop PCs, errors in prescription handling and, in this case, problems with medical records.

The VA data breach report states that the veteran learned that notes about his treatment for traumatic events at the Albuquerque Veterans Center somehow ended up in the hands of an Army doctor at Ft. Benning, Ga. The doctor was supposed to be clearing the solider for deployment to Afghanistan.

On the basis of those notes, which the system should have kept confidential, the Army doctor blocked the solider from deploying with his unit.

The VA report said the veteran "was extremely upset at this disclosure."

Baker said VA is working with the Pentagon to determine what happened.

"We try to be very, very careful with those things (medical health records), in fact, we're trying to find out how that could possibly have happened, with all the safeguards that we have in place," Baker said. "The concerning piece here is that it should not have happened one time. We have to ensure that it's not happening now. It's a pretty complex area of privacy when you're talking about constraining what two federal agencies can share with each other."

Baker said his staff is approaching their investigation from two vantage points: privacy, which means policies and procedures should be in place to prevent this inadvertent disclosure to take place, and from an information technology standpoint. Baker said the Pentagon doctor was able to see something out of a veterans Vista record that they were not supposed to be able to see.

"I believe the policy has been that this information should not have been released outside the VA," he said. "Since this is an electronic connection between AHLTA and the VA that is intended to share information, how did this particular information, that was not supposed to be shared, actually make it through to the DoD side? We believe the protections are there that would protect this from happening."

Baker added that based on what he has learned so far, it may not be appropriate to enter progress notes into the Vista system if they can't keep such sensitive information from accidental sharing with DoD doctors.

Baker said a solution may lie in "a reminder to our clinicians to make certain that in certain sensitive areas, things are not entered into progress notes that are viewable outside of the VA."

At this point, Baker said the investigation into the incident involving the Army veteran is continuing.

Officials with the VA's Readjustment Counseling Service are slated to travel to Ft. Benning to examine the Army medical computers to try to see what the Army physician saw on his screen. In addition, they also are trying to determine whether a violation of federal health privacy rules might have taken place.

Baker said representatives from both the VA and Pentagon are holding "very productive" discussions to determine exactly what happened to this Army veteran's health record.

A Military Health System official said in an e-mailed statement about the incident, "We feel as though it is inappropriate for us to release any statements or make assumptions prior to VA concluding their assessment."